mitral regurgitation

MR

incompetent MV causing backward systolic flow

MR Murmur

blowing or high pitched Holosystolic murmur that radiates to the axilla

Holosystolic

throughout systole

primary causes of MR

MV Leaflet/Chordae abnormalities/dysfunction: Myxomatous D (MVP), RHD, MAC or congenital anomalies (cleft MV)

cleft MV

slit like hole of the MV leaflet (usually AMVL)

RHD causes

leaflet thickening/calcification, scarring and chordae is fused to the commissures

secondary causes of MR

LV dilation/dysfunction with normal MV leaflets

LV dilation/dysfunction with normal MV leaflets (secondary MR) is caused by

dilated annulus, uneven pap muscle alignment or Ischemic MR or MS

Annular dilation/maligned papillary muscles causes

tethering/tenting of the leaflets in systole

Ischemic MR is caused by

pap muscle dysfunction, regional function of the inf lat wall or diffuse LV dilation/dysfunction

other secondary causes of MR

Leaflets are flail, prolapsed or stenotic or Pap Muscles have calcification/fibrosis, ischemia or are ruptured

MR causing LA volume overload

LAVO -> LAE -> inc LAP -> LA thrombus (can embolize)

MR increases

PRELOAD -> LVVO

LVVO leads to

LVVO -> LV dilation -> hyperkinesis (LV compensating for dilation) -> inc SV (from inc P within the chamber) -> LVH

Long standing MR causes

PH and HF

acute (severe) MR

causes a sudden vol overload and the LA is unable to compensate causing a PUL EDEMA

MR : Signs and Symptoms

irregular rhythm and palpitations

MV repair/replacement is for

primary MR from a valve abnormality (even if pt is asymptomatic) before they can go into LV failure

MV repair vs replacement

repair is preferred since pt have a better recovery/ability to tolerate the procedure

MV repair

connects leaflets, tightens the annulus (annuloplasty) and removes excess valve tissue

MV clip

Rheumatic Mitral Stenosis

usually also has MR (from commissural Fusion and dilated MV Annulus)

thrombus

anytime blood collects a thrombus can form

1 is from

defects that inhibit coaptation: thickening/calcification, prolapse, dilation or flail leaflets/chordae

2

LAE

3

LVVO pattern (LV dilation with hyperkinesis)

4

LVVO leads to LVH

5

RV Dilation

6

RV dilation

7

LVVO pattern

8

LVVO leads to LVH

9

AOV notching (partial mid systolic closure) from a sudden dec in vol leaving the LV (from backflow into the LA)

10

LAE

additional m mode findings

PH and RAE

CFD

turbulent systolic flow. use mult views to avoid missing small/eccentric jets

most popular method to evaluate MR

CFD (BP and CFD gain affect jet size)

Severity Scale uses

Regurgitant jet area/LA area, CWD spectral strength/shape and PWD mapping

grade 1 or mild MR

MR jet is just past the MV leaflets

grade 2 or Moderate MR

MR jet is 1/3 the way into the LA

grade 3 or Moderate to Severe MR

MR jet is 1/2 the way into the LA

grade 4 or Severe MR

MR jet is in the mid to back wall of the LA

vena contracta

VC >7 cm is severe MR

LV dilation jet

LV dilation has a central jet

ischemic MR jet

ischemic MR has an eccentric posterior directed jet

MVP jet

anterior jet is PMVL MVP and posterior jet is AMVL MVP

FC

VC

area

CFD vs CWD

Use CFD to find the peak jet and optimize the doppler angle then place the CWD focus in the MR jet to find the peak waveform

Asymmetric shape

Asymmetric MR waveform indicates a rapid rise in LAP from significant MR

Decreased MR velocity

MR velocity <4 indicates an elevated LAP from significant MR

lap equation

LAP = systolic BP - MR gradient 

PISA uses the

FC method to estimate the size of the coaptation defect

PISAr

mid systolic peak where the color changes from blue to yellow

PISAr is the

Greatest source of error in measuring PISA

PISA Steps

acquire 1. PISAr 2. MR max velocity 3. aliasing velocity (Va) 4. MR VTI

Pulmonary venous flow into the LA

depends on the P difference between the PV4 and LA

in 4C

R and L lower PV4

in 5C

R and L upper PV4

Normal PV4

the systolic component (S wave) is larger than the diastolic component (D wave)

wave in Moderate to Severe MR

S wave dec and D wave inc

wave in Severe MR

S wave reversal and inc D wave (PV4 systolic flow reversal)

dP/dt

dP/dt is the Change in LV P over the change in time

PV4 reversal

dP/dt is the

Measurement of directional LV contractility (LV systolic function)

if CO goes down

dP/dt is abnormally low